This Decision issues Guidelines for Diagnosis, Treatment, and Prevention of Infection of Pneumonia Caused by Avian Influenza A/H5N1 Virus. It applies to all medical facilities and provides detailed regulations on diagnosis, treatment, isolation, and prevention of infection.
적용 범위
State-owned, semi-state, and private medical facilities; healthcare workers; and people who have contact with diseased poultry or areas affected by avian influenza.
핵심 사항
- Suspected patients with pneumonia caused by the Avian Influenza A/H5N1 virus must be isolated immediately and treated promptly with oseltamivir.
- Acute respiratory management includes positioning, oxygen supply, CPAP, and artificial ventilation when necessary.
- Corticosteroids are prescribed for severe cases during the progression phase.
- Patients must be closely monitored for respiratory status and other symptoms.
- Strict infection control measures at hospitals, including patient isolation, restricted contact, personal hygiene, and waste management.
🌐 이 문서의 사회적 영향
- Positive impact: Reducing mortality from pneumonia caused by the Avian Influenza A/H5N1 virus through early diagnosis and timely treatment.
- Negative impact: Increased healthcare costs due to the need for isolation, strict handling of patients and healthcare workers.
❓ 자주 묻는 질문
What factors are used to diagnose suspected pneumonia caused by the Avian Influenza A/H5N1 virus?
Suspected diagnosis is based on epidemiological factors (contact with diseased poultry or affected areas) and respiratory symptoms such as fever, cough, and shortness of breath.
When are patients prescribed corticosteroids?
Corticosteroids are prescribed for severe cases during the progression phase.
What criteria are used for definitive diagnosis?
Definitive diagnosis is based on a positive viral test for Avian Influenza A/H5.
When can patients be discharged?
After seven days without fever following cessation of antibiotics, stable chest X-rays and laboratory tests, and a negative viral test for Avian Influenza A/H5.
What preventive measures should healthcare workers implement?
Full use of protective equipment such as N95 masks, gloves, gowns, and adherence to disinfection procedures when handling specimens.
전문
DECISION OF THE MINISTER OF HEALTH
Regarding the issuance of Guidelines for Diagnosis, Treatment, and Prevention of Viral Pneumonia Infection
and intensive care unit for pneumonia virus infection
THE MINISTER OF HEALTH
Pursuant to Decree No. 49/2003/NĐ-CP dated May 15, 2003 of the Government stipulating the functions, tasks, and organizational structure of the Ministry of Health;
Considering the Minutes of the Meeting of the Research Council on Diagnosis and Treatment of Severe Acute Respiratory Infections Caused by Influenza Virus held on November 4 and 7, 2005;
At the proposal of the Director of the Department of Treatment,
DECISION:
Article 1. Issuing with this Decision the "Guidelines for Diagnosis, Treatment, and Prevention of Viral Pneumonia Infection"
Article 2. The "Guidelines for Diagnosis, Treatment, and Prevention of Viral Pneumonia Infection" shall apply to all state-owned, semi-state-owned, and private healthcare facilities.
Article 3. This Decision takes effect fifteen days from the date of publication in the Official Gazette. Decree No. 3422/2004/QĐ-BYT dated September 30, 2004 issuing the "Guidelines for Diagnosis, Treatment, and Prevention of Viral Pneumonia Infection" is hereby repealed.
Article 4. The Heads of the Office, Directors of the Department of Treatment - Ministry of Health, Directors of Hospitals and Institutes under the Ministry of Health, Directors of Provincial Health Departments, and Heads of Health Services of various sectors are responsible for implementing this Decision.
GUIDELINES FOR DIAGNOSIS, TREATMENT
AND PREVENTION OF VIRAL PNEUMONIA INFECTION
(Issued together with Decision No. 37/2005/QĐ-BYT dated November 11, 2005)
of the Minister of Health)
Influenza viruses have caused many large outbreaks worldwide with high mortality rates. There are three types of influenza virus: A, B, and C, among which types A and B frequently cause illness in humans. Strains may change annually.
Many countries around the world have reported cases of infection with type A (H5N1) influenza virus with high mortality rates. Recently, there have been several patients admitted to hospitals due to type A (H5N1) influenza virus infection in our country. The disease progresses rapidly, does not respond to conventional treatment methods, and has a high mortality rate.
I. DIAGNOSIS
Based on the following factors and symptoms:
1. Epidemiological Factors
- Contact with sick poultry within two weeks prior (raising, selling, transporting, slaughtering, eating sick poultry, consuming raw blood, etc.), or living in areas affected by avian influenza.
- Close contact with confirmed influenza patients or those who died from pneumonia of unknown cause.
2. Clinical Symptoms
The disease progresses acutely and may present with the following manifestations:
· Signs of bacterial infection:
- Fever above 38°C, possibly with shivering°Respiratory symptoms:
· - Coughing, usually dry cough, chest pain, rarely upper respiratory tract inflammation symptoms.
- Shortness of breath, rapid breathing, cyanosis.
- Crackles and moist rales heard in the lungs, which may lead to progressive acute respiratory distress syndrome (ARDS).
Circulatory symptoms:
- Rapid heart rate, sometimes shock.
· Other symptoms:
- Headache, muscle pain, diarrhea, altered consciousness,
· - Multiple organ failure.
3. Laboratory Tests
a) Chest X-ray (mandatory):
Extensive infiltration on one or both sides, progressing rapidly. Chest X-rays should be taken 1-2 times daily during the acute phase.
b) Blood tests - Blood cell count:
+ White blood cell count: normal or decreased.
- Arterial blood gas analysis: hypoxemia when the disease worsens:
+ PaO2 less than 85 mmHg, may decrease rapidly (below 60 mmHg). The PaO2/FiO2 ratio is below 300 in acute lung injury (ALI) and below 200 in progressive ARDS.
c) Microbiological diagnosis:
- Virus:2 + Sample collection:2. Deep throat swab2 . Nasopharyngeal aspirate
. Bronchoalveolar lavage fluid
sent to a laboratory capable of testing to determine the cause:
+ Perform RT-PCR to identify influenza A/H5 virus
- Bacteria:
+ Culture pleural fluid, endotracheal aspirate, and blood if superinfection is suspected.
+ Collect samples as above
+ Isolate bacteria according to standard procedures.
4. Diagnostic Criteria for Cases:
a) Suspected Diagnosis:
When all of the following criteria are met:
- Fever of 38°C or higher
- One of the following respiratory symptoms: cough, shortness of breath
- Epidemiological factor.
b) Probable Diagnosis: - Meets the criteria for suspected diagnosis
- At least one laboratory test suggestive of viral pneumonia:°+ Radiographic findings consistent with influenza progression
+ Normal or decreased white blood cell count
c) Confirmed Diagnosis:
- Positive viral test for influenza A/H5
5. Clinical Grading:
Based on:
- Degree of hypoxemia:
+ Prioritize arterial blood gas monitoring
+ Widespread use of pulse oximetry
- Degree of radiographic lung involvement: mandatory chest X-ray.
a) Severe:
- Shortness of breath, cyanosis
- SpO2 less than 90%
- PaO2 less than 60 mmHg
- Chest X-ray: extensive bilateral infiltration2.
- Possible multiple organ failure, shock.
b) Moderate:
- SpO2 between 88% and 92%
- PaO2 between 60 and 80 mmHg2 < 88%
- Chest X-ray: localized bilateral or unilateral infiltration.2 c) Mild:
- No shortness of breath
- SpO2 greater than 92%
- PaO2 greater than 80 mmHg
- SpO2 between 88% and 92%
- PaO2 between 60 and 80 mmHg2 - Chest X-ray: localized unilateral infiltration or indistinct lesions.
- Chest X-ray: localized bilateral or unilateral infiltration.2 II. TREATMENT
A. General Principles
- Suspected patients must be isolated.
- Antiviral drugs (oseltamivir) should be administered as early as possible even in suspected cases of viral pneumonia.
- PaO2 between 60 and 80 mmHg2 > 92%
- Chest X-ray: localized bilateral or unilateral infiltration.2 - Respiratory resuscitation is fundamental.
- Treat multiple organ failure (if present).
B. Treatment of Acute Respiratory Failure
a) Patient Positioning
- Supine position with head elevated at 30 degrees
b) Oxygen Supply
+ Nasal cannula oxygen: 1-5 liters per minute to maintain SpO2
+ Simple face mask oxygen: 6-12 liters per minute when nasal cannula oxygen does not maintain SpO2
+ Non-rebreathing face mask: sufficient flow to prevent bag collapse during inspiration, indicated when simple face mask is ineffective.
c) Continuous Positive Airway Pressure (CPAP)
- CPAP is indicated when oxygenation is not improved by oxygen therapy, SpO2°.
- Initiate CPAP:
+ Select appropriate mask (adult, older child) or nasal cannula (small child).2 > 90%.
+ Start with CPAP = 5 cmH2O2 > 90%.
+ Adjust CPAP level clinically in increments of 1 cmH2O to maintain SpO2
> 90%. Maximum CPAP level可达10 cmH2O。
d) Mechanical Ventilation:2 < 90%.
- Indications:
+ CPAP or oxygen therapy does not improve oxygenation (SpO2
< 90% with CPAP = 10 cmH2O).2O
+ Patient begins to show signs of cyanosis, rapid shallow breathing.2- Principles of mechanical ventilation:2 > 90%. The maximum CPAP level that can be reached is 10 cmH2O.
d) Mechanical ventilation:
- Indications:
+ CPAP or oxygen therapy does not improve hypoxemia status (SpO2 < 90% with CPAP = 10 cmH2O).
+ Patient begins to show signs of cyanosis, rapid shallow breathing.
- Principles of mechanical ventilation:
Objective: SpO2 > 92% with FiO2 equal to or below 0.6
If the above objective is not achieved, an acceptable level of SpO2 > 85%.
- Non-invasive mechanical ventilation using BiPAP (see Appendix 3):
+ Non-invasive mechanical ventilation using BiPAP is indicated for patients who have respiratory failure but remain conscious, cooperative, and have good coughing ability.
- Invasive mechanical ventilation (see Appendix 4):
+ Indicated when the patient has severe respiratory failure that progresses despite non-invasive mechanical ventilation.
+ Set volume-controlled ventilation mode, with tidal volume (Vt) from 8 to 10 ml/kg, frequency 14 to 16 breaths/min, inspiratory-to-expiratory ratio (I/E) = 1/2, positive end-expiratory pressure (PEEP)=5, and adjust FiO2 to achieve SpO2 > 92%. If progression to acute respiratory distress syndrome (ARDS) occurs, proceed with mechanical ventilation according to the protocol for protective lung ventilation (see Appendix 4).
+ For children, pressure-controlled ventilation (PCV) may be used. If ineffective, switch to volume-controlled ventilation (VCV).
C. Other resuscitation measures
- Fluid administration: Ensure fluid balance, maintain urine output in adults at approximately 1200-1500 mL/day, and avoid pulmonary edema (crackles, jugular vein distension, patient weight...). If possible, central venous catheterization should be performed and central venous pressure (CVP) maintained at 5-6 cmH2O (not exceeding 6.5 cmH2O). If more than 2 liters of crystalloid solution does not raise blood pressure, substitute with colloid solution. Where conditions permit, maintain serum albumin levels at ≥ 35 g/L.
- Vasopressors: Administer vasopressors early, such as dopamine or noradrenaline combined with dobutamine to maintain systolic blood pressure ≥ 90 mmHg.
- Acid-base balance: Maintain acid-base balance, especially during protective lung ventilation, with pH ≥ 7.2.
- When the condition progresses to multiple organ dysfunction syndrome (MODS), apply the resuscitation protocol for MODS (see Appendix 8).
- In places with appropriate facilities, continuous renal replacement therapy can be performed to support treatment of MODS.
D. Supportive Treatment
1. Corticosteroids:
- Indicated for severe cases, during the progressive stage. One of the following drugs may be used:
· methylprednisolone: 0.5 - 1 mg/kg/day for 7 days, intravenous injection.
· hydrocortisone: 100 mg twice daily for 7 days, intravenous injection.
· depresolone: 30 mg twice daily for 7 days, intravenous injection.
· prednisolone: 0.5 - 1 mg/kg/day for 7 days, oral intake.
Note: Monitor blood glucose levels.
2. Fever:
Use antipyretics only if body temperature exceeds 39°C with paracetamol.
3. Ensuring nutritional support and care:
Nutrition:
+ Mild cases: oral feeding.
+ Severe cases: enteral nutrition via nasogastric tube.
+ If unable to eat, provide parenteral nutrition.
Pressure ulcer prevention: Use water mattresses, massage, and change positions regularly.
Respiratory care: Assist with coughing and expectoration; chest physiotherapy; suctioning.
E. Antibiotic Therapy
1. Antiviral drugs: oseltamivir (Tamiflu):
Children aged 1 to 13 years: oral suspension based on body weight: < 15 kg: 30 mg twice daily; 16 - 23 kg: 45 mg twice daily; 24 - 40 kg: 60 mg twice daily for 7 days.
Adults and children over 13 years: 75 mg twice daily for 7 days.
Monitor liver and kidney function to adjust dosage accordingly.
2. Antibiotics:
- Broad-spectrum antibiotics or combination of two or three antibiotics may be used if hospital-acquired infection is suspected.
- At commune and district levels, antibiotics for community-acquired pneumonia such as first and second generation cephalosporins, co-trimoxazole, azithromycin, doxycycline, gentamicin... may be used.
F. Discharge Criteria
- Absence of fever 7 days after stopping antibiotics.
- Stable blood tests, chest X-rays.
- Negative test for avian influenza A/H5 virus.
III. INFECTION CONTROL
1. Principles
- Strict isolation and infection control measures must be implemented. Healthcare workers must direct suspected patients to designated healthcare facilities for examination, classification, and isolation if necessary.
2. Isolation area organization in hospitals
- Organize isolation areas as for other dangerous infectious diseases.
- Limit access to isolation areas.
- Place a basin of 5% chloramine B or 0.5% chlorhexidine solution at the entrance of patient rooms for hand washing before entering and after leaving, and place a cloth soaked in chloramine B or formaldehyde at the floor entrance so that everyone must walk through it.
3. Prevention for patients and visitors
- Early detection and isolation of suspected cases in separate rooms.
- Confirmed patients must be placed in single rooms, not sharing rooms with suspected cases.
- All patients must wear standard masks. Suspected patients must wear standard masks both inside and outside their rooms.
- Patients requiring X-ray, laboratory tests, or specialty consultations must be conducted at bedside. If not feasible, prior notification to relevant departments is required so that healthcare staff can prepare appropriate personal protective equipment. Patients must wear masks and gowns during transport within the hospital.
- Limit family visits to patients in hospitals. Prohibit family members and visitors from entering isolation areas.
- Family members visiting patients outside isolation areas must wear masks.
- Place a basin of 5% chloramine B or 0.5% chlorhexidine solution at the entrance of patient rooms for hand washing before entering.
4. Prevention for healthcare workers
- Personal protective equipment includes: N95 masks, protective goggles, face shields, disposable gowns, gloves, caps, shoe covers or boots.
- Each healthcare worker in strict isolation areas must be provided with and wear full personal protective equipment before contact with patients and respiratory secretions at the start of each shift. After the shift, discard all personal protective equipment in infectious waste bins and undergo decontamination procedures, including showering and changing clothes before leaving the hospital.
- Laboratory specimens: Must be placed in a plastic bag or transport container as prescribed before being sent to the laboratory.
- Surveillance: Establish a list of healthcare workers directly caring for patients and those working in departments with patients. These staff members will self-monitor daily. Those showing signs of suspected infection will be examined, tested, and monitored like suspected severe influenza patients.
- Immediately report suspected and confirmed cases to the local Preventive Health Center and the Ministry of Health.
5. Handling medical equipment, textiles, and patient-use items:
- Medical equipment: Reusable equipment must be disinfected immediately, then transferred to the washing room for cleaning and sterilization according to regulations.
- Patient-use items: must be washed and sanitized with soap and disinfectants daily and whenever soiled. Each patient should have their own hygiene and nutrition supplies.
- Textiles: Steam under pressure before washing. Apply transportation and handling procedures as for contaminated textiles. Collect textiles in yellow plastic bags before transporting to the laundry. Soak textiles in disinfectant solutions. Add additional disinfectant concentration during washing if necessary.
6. Environmental and hospital waste management
Follow the procedures for environmental and waste management as prescribed for contaminated cases.
7. Patient transport
- Principles:
+ Minimize patient transport.
+ Only transport patients when their condition exceeds the treatment capacity of the facility.
+ Ensure safety for both patients and transport personnel (drivers, healthcare workers, family members, etc.) according to infection prevention guidelines.
- Transport personnel must wear full personal protective equipment: N95 masks, disposable gowns, face shields, gloves, and hats.
- Disinfect ambulances after each patient transport using standard disinfectants.
8. Handling deceased patients
- Deceased patients must be embalmed on-site according to disease control regulations, using chemicals such as chloramine B and formaldehyde for disinfection.
- Transfer deceased patients to burial or cremation sites using dedicated vehicles and ensuring compliance with infection control regulations.
- Within 24 hours after death, cremation or burial must occur, preferably through cremation.
9. General preventive measures:
- Personal hygiene, nasal irrigation, gargling with antiseptic medications
- Taking Vitamin C.
10. Antiviral prophylaxis:
Target group: Healthcare workers and those directly caring for patients infected with Influenza A/H5
Dosage: oseltamivir 75 mg, 1 tablet/day for 7 days.
11. Specific vaccine prevention:
Research is currently underway for a specific vaccine against the H5N1 strain of Influenza A virus./.
DEPUTY MINISTER
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